Provider Demographics
NPI:1053421818
Name:ABIGAIL GUEVARA PHD PC
Entity type:Organization
Organization Name:ABIGAIL GUEVARA PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ABIGAIL
Authorized Official - Middle Name:GUEVARA
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:616-866-4830
Mailing Address - Street 1:16 N MONCOE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341
Mailing Address - Country:US
Mailing Address - Phone:616-866-4830
Mailing Address - Fax:616-866-4944
Practice Address - Street 1:16 N MONCOE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341
Practice Address - Country:US
Practice Address - Phone:616-866-4830
Practice Address - Fax:616-866-4944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011335103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
11277623OtherCAQH
680DI15940OtherBCBS
162677OtherVALUE OPTIONS
7000023702OtherPRIORITY HEALTH
239038OtherUBH
Q31193Medicare UPIN
MIOP3039001Medicare ID - Type Unspecified